Oncology group criticizes insurers' cancer care guidelines

Doctors who were involved in the unsuccessful Highmark-UPMC cancer treatment collaboration said generally accepted care guidelines were much needed in Pittsburgh.

By Kris B. Mamula / Pittsburgh Post-Gazette

Doctors at the two leading health care systems in Pittsburgh — Allegheny Health Network and UPMC — use different guidelines to treat people with cancer, but they say their programs are not interfering with care, despite a warning by a professional group that such guidelines too often emphasize cost control over what’s best for the patient.

The Alexandria, Va.-based American Society of Clinical Oncology criticized the clinical pathways that insurers urge cancer doctors to follow as often being rigid, failing to account for individual patient differences and sometimes delaying care. The guidelines can also “get in the way of better outcomes,” according to Robin Zon, chair of the medical society’s task force on clinical pathways.

The group said deviation from an insurer’s guidelines is often punished. “When doctors diverge from a clinical pathway, even for well-justified reasons, payers are likely to either deny coverage or require prior authorization, which can delay treatment and threaten patients’ health,” Dr. Zon said in a prepared statement.

The clinical oncology society’s policy statement, which appeared in the Jan. 12 issue of the Journal of Oncology Practice, criticized the lack of transparency in how the guidelines were developed and the proliferation of different ones.

“The sheer number of pathways has created intense administrative burdens because oncology practices are forced to sift through the various requirements and preferences of the pathway program of each payer on a patient-by-patient basis,” the statement read.

The issue of which clinical steps to follow has been around for years. Such guidelines are seen as a way to lower the cost of often very expensive cancer care by eliminating variations in treatment that drive up costs without improving care. The cost of cancer care in the U.S. in 2010 was $124.5 billion, driven by various forms of treatment such as surgery, radiation and medical oncology.

Treatment for pediatric leukemia can reach as high as $34,000 a month for some newly developed treatments, according to an industry study in 2011.

Starting in 2005, Highmark Inc. and UPMC undertook an ambitious effort to standardize cancer care together, with the goal of driving out duplication and inefficiencies. The wheels fell off the effort five years later over larger contractual issues between the Pittsburgh health care titans.

AHN has been rolling out cancer treatment guidelines developed by the National Comprehensive Cancer Network, a Fort Washington, Pa.-based nonprofit.

UPMC cancer doctors use clinical pathways developed by Via Oncology LLC, a wholly owned UPMC for-profit subsidiary and one of at least six similar companies nationwide.

The National Comprehensive Cancer Network’s guidelines are used by 26 cancer centers nationwide, including John Hopkins Medicine, the Cleveland Clinic and Memorial Sloan Kettering. Via Oncology’s pathways are used by 1,300 providers in community, hospital and academic-based cancer centers in 23 states, including the Dana Farber Cancer Institute.

Other insurers recommend the use of still other guidance in the treatment of cancer.

The guidelines at AHN do not delay care or overly focus on holding down costs, said David Parda, chairman of AHN’s Cancer Institute. “Just because you do more stuff doesn’t mean you optimize care,” Dr. Parda said. “The name of the game is to put all of these modalities together.”

Doctors who were involved in the unsuccessful Highmark-UPMC cancer treatment collaboration said generally accepted care guidelines were much-needed in Pittsburgh.

Some doctors, for example, were administering twice the recommended amount of certain medications, driving up costs without improving care.

And the need to control the cost of cancer care is pressing: By 2020, the cost of cancer treatment at current expenditure levels will increase 27 percent to $157.8 billion from $124.5 billion in 2010, according to the 2011 study.

Via Oncology medical director Peter Ellis said doctors are bombarded with competing cancer treatment guidelines from insurers, but his company was different.

“The pathways that insurance companies are pushing on physicians are nothing more than a drug formulary program and they are burdensome,” Dr. Ellis said. “It’s really not a workable system.”

“Everybody is reading the same literature,” he said. “The magic is that Via Oncology pathways are based on the literature and made by providers, who use them to provide good care.”

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